When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Compare muscle strength bilaterally.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.

Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.

Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.

Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.

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Correct Answer is C

Explanation

Choice A reason: Offering reassurance that she is not alone is not the best action to take first. It may sound dismissive of her feelings and make her feel more isolated.

Choice B reason: Explaining that alternative treatment options may be helpful is not the best action to take first. It may give false hope or imply that the wife is not accepting the reality of her husband's condition.

Choice C reason: Encouraging the wife to share her feelings is the best action to take first. It shows empathy and respect for her emotional state. It also allows the nurse to assess her coping skills and provide appropriate support.

Choice D reason: Reminding her that her husband may still live a long time is not the best action to take first. It may contradict the medical prognosis and make the wife feel more confused and anxious.

A. Muscle strength and tone B. Limitations to range of motion C. Presence of rebound phenomenon D. Degree of neurosensory impairment

Correct Answer is D

Explanation

Choice A reason: Muscle strength and tone is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have musculoskeletal problems, but it does not indicate the risk of thermal injury.

Choice B reason: Limitations to range of motion is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have joint stiffness or pain, but it does not indicate the risk of thermal injury.

Choice C reason: Presence of rebound phenomenon is not the most important assessment for the nurse to perform prior to the application of a heating pad. It is a sign of peritoneal inflammation that occurs when pressure is released from the abdomen. It has nothing to do with the application of a heating pad.

Choice D reason: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. It indicates the client's ability to perceive heat and pain sensations. If the client has impaired neurosensory function, the nurse should avoid using a heating pad or use it with caution and frequent monitoring.

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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